• Image-9

  • CareFlight Application

    This membership benefit for you and your family if provided to you by North Texas Karters. This form must be completed and turned in to NTK to activate your membership and receive its benefits.

  • By submitting this application, I agree (on my behalf and on behalf of my family) in consideration of the benefits provided to abide by the terms of the Caring-Heart Membership Program, which are shown on the back of this application. I request payment of authorized Medicare or other insurance benefits to me, or on my behalf, to be paid to CareFlite for any emergency services and supplies furnished to me or my household family members by CareFlite. I authorize any holder of any of my medical information or that of my household family members to release that information to CMS, its agents or carriers, or CareFlite in order to determine benefits payable on my behalf or on behalf of my family members, now and in the future. This agreement and authorization is executed on my own behalf and on behalf of the other members of my household, if they are minors or otherwise unable to sign. I understand that under Texas rule 157.11 if I or a household member is a Medicaid recipient, than I am not allowed to have them on this application. Therefore I am stating that I have not listed on this application anyone that is a Medicaid recipient. If a household family member subsequently becomes a recipient of Medicaid, I will notify CareFlite in writing of this change immediately. I warrant that all of the information on this application is true and correct. CareFlite reserves the right to request documentation to verify the accuracy of any such information. I acknowledge that membership in CareFlite’s Caring-Heart Membership Program is an EMS membership in a program sponsored by CareFlite and is not a membership in CareFlite’s non-profit entity as the term "membership" is contemplated under the Texas Non-Profit Corporation Act.

  • MASTER MEMBER

  •  -
  •  - -
    Pick a Date

    • ADD: Additional Family Members in Your Household 
    •  - -
      Pick a Date
    •  - -
      Pick a Date
    •  - -
      Pick a Date
    •  - -
      Pick a Date
    •  - -
      Pick a Date
    • Stopper 

    • By submitting here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By submitting here, you are waiving that right. After consent, you will receive a copy of your agreement via email. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

    • Clear
    • Terms and Conditions 

    • Caring-Heart Membership Terms and Conditions

      PERSONS COVERED: This Agreement covers the household family members listed on the application, so long as they remain full-time residents (including college students) of my household. New residence family members may be added, others deleted or the household location changed by written notice to CareFlite at the address shown above. Added members will be effective as of the date the information is received by CareFlite. Medicaid recipients may not enroll by law.

      EFFECTIVE DATE: This application will be effective on the date agreed to in the contract between CareFlite and the company shown on the reverse side of this form.

      BENEFITS: Payment of the membership fee and compliance with the terms of this program/agreement entitles the member to the following benefits:

      1. Emergency helicopter air ambulance services originating within 150 miles of DFW Airport for medically necessary advanced or basic life support emergency transport services from CareFlite as a result of an emergency medical condition shall pay nothing out of pocket, unless otherwise specified herein.
      2. Emergency fixed wing air ambulance services for patients needing a higher level of care originating within 500 miles of DFW Airport and within the United States shall pay nothing out of pocket. For non-medically necessary fixed wing transports, CareFlite will make its best efforts to obtain an insurance pre-authorization. For fixed wing air ambulance service that are not medically necessary and/or operated for patient or family convenience, CareFlite will give members a 50% discount from its standard rates.
      3. CareFlite’s ground ambulance and 911/EMS service will be available with its service areas. These benefits will follow the rules of this Air Ambulance membership program.
      4. If CareFlite has any agreements for the reciprocal honoring of a membership benefit with other air/ground EMS providers, all Members of CareFlite shall be covered by such agreement. A list of any such agreements can be found at www.careflite.org.


      PAYMENT FOR SERVICES: I understand that I am responsible for payment for any services provided to me by CareFlite, but that my membership will assist me by discharging that part of my financial liability that is not covered by insurance for those CareFlite services specified in this Agreement. This benefit is subject to certain limitations specified in this agreement. As a condition of receiving this benefit, I hereby assign (hand over) to CareFlite all rights and benefits that I or the other family members of my residence have under any and all medical, health, supplemental, worker’s compensation, liability, auto or homeowner’s insurance policies or plans, or from other third party payers or sources which provide coverage or would otherwise pay for ambulance services. Such payment sources are collectively referred to in this agreement as “insurance”. I authorize the payment of all insurance benefits or payments to CareFlite. I understand that CareFlite will, whenever it deems it feasible, file claims for and directly collect the benefits payable from insurance up to the amount of CareFlite’s charges for its services. When requested by CareFlite, I agree to complete any forms and take any other reasonable action that may be necessary to collect such amounts. If I or anyone on my behalf receives any insurance or other third party payments for services provided by CareFlite, I will promptly forward those payments to CareFlite at 3110 S. Great Southwest Parkway, Grand Prairie, Texas 75052.

      LIMITATIONS and CONDITIONS: Membership benefits extend to CareFlite’s critical care, advanced or basic life support helicopter and fixed wing air ambulance services staffed with nurses, paramedics and pilots, Specialty Care Transport (a ground transport staffed similarly to CareFlite’s air ambulance services) as well as ground ambulances staffed with quality trained paramedics and EMTs. Member benefits are not applicable to services rendered by any other provider. As a condition of receiving the benefits of membership with respect to any air or ground ambulance transport, members with insurance agree to and must comply with all coverage conditions of their applicable insurance program for such transport. Some insurance programs require the insured person to obtain prior authorization of payment for non-emergency, yet medically necessary air ambulance services. (This requirement typically applies to fixed wing air ambulance and inter-facility ground ambulance only but not to helicopter or 911/EMS emergency services.) Non-insured household family members will automatically receive a 50% membership discount on CareFlite’s standard charges for the services rendered. Some plans require certain documentation from the insured within a specified time limit or the plan(s) deny or reduce coverage for ambulance services. In the event the member with insurance forfeits coverage by failing to comply with these types of requirements for a transport that would otherwise be covered by insurance, the member will then forfeit membership benefit for failing to so comply and their membership can be revoked at CareFlite’s discretion. Membership is available for sale only in those counties or jurisdictions shown on CareFlite’s website www.careflite.org . Ground ambulance benefits are available to all members but only in CareFlite’s ground ambulance service areas. The member must hold a membership that is in good standing at the time of service and the transport must originate in CareFlite’s deemed service area with CareFlite as the transporting agency. CareFlite reserves the right to deny or revoke any membership for reasonable cause. If membership is revoked then all balances are due in full. CareFlite may terminate the membership program at any time upon notice to the members. If CareFlite terminates the program, members will have any unused, prorated portion of their membership fee returned. To protect member fees, CareFlite maintains a bond with an A rated insurance company. CareFlite’s Membership benefits are honored by certain other medical transport programs. Visit www.careflite.org for complete details.

    • Stopper 
    •  
    • Should be Empty: